presentation of snake bite with respiratory paralysis

1. PAF Hospital , Islamabad
Morbidity and Mortality Meeting
Case Presentation
Dr Afrah Malik - Resident Medicine
Dr Sohaib Ahmad - House Officer
26-08-23

2. PAF Hospital , Islamabad
Learning Objectives
 Patient demographics
 Clinical history and course of events
 Differential diagnosis
 Outcome
 Analysis
 Literature Review
 Key Learning Points

3. PAF Hospital , Islamabad
Patient Demographics
• Siddique Usman
• MR# 1123071971
• 14 years old /Male
• Resident of Talagang
• No known comorbids
• Date of admission:18th July,2023
• Admitted in MICU via ER
• Diagnosis: Snakebite Envenomation

4. PAF Hospital , Islamabad
Events
• 1 day back patient developed crampy abdominal pain on
waking up in morning
• later on, lower limbs weakness followed by upper limbs
weakness, difficulty in opening eyes
• History of sleeping on a mattress on the floor

5. PAF Hospital , Islamabad
Events
• At tehsil hospital, he was drowsy
• Transferred to DHQ Talagang, due to respiratory distress
• Moved to tertiary care hospital in Rawalpindi with oxygen
support

6. PAF Hospital , Islamabad
Events- Tertiary care hospital
• GCS: 8/15
• BP 100/70
• Pulse 140bpm
• spO2 60% at room air
• obvious respiratory distress
• Bilateral Ptosis
• Left Babinski sign was positive
• Pupils- sluggish reaction
• Decreased breath sounds in the base of right lung
• Excessive mouth frothing
• Urinary incontinence

7. PAF Hospital , Islamabad
Events- Tertiary care hospital cont.
• Suspected case of neurotoxic snake bite with respiratory failure
• history of weakness of limbs not present initially as patient was
not conscious
• Rx: neostigmine, atropine and anti-snake venom
• Electively intubated
• Transferred due to non-availability of ventilator

8. PAF Hospital , Islamabad
Events- PAF hospital
• Admitted in ICU
• Ventilatory support:
• SIMV (Volume control) with pressure
support mode
• PEEP 4cm H2O, spO2 94%
• FiO2 70%
• Tidal Volume 300ml
• Respiratory rate 18/min
• Sedated and paralyzed
• BP 130/70
• pulse 172bpm
• temperature 100F
• BSR 112mg/dl
• Pupils sluggish
• plantars BL mute
• Healing laceration below his
right little toe
• No fang marks
• bilaterally decreased lung air
entry
• Initial ABGs: Type 2
respiratory failure
• pH 7.25, pO2 61, pCO2 39,
HCO3 17

9. PAF Hospital , Islamabad
Initial Differentials:
• Snakebite with Neurotoxicity and Respiratory failure
• Myasthenia Gravis (MG)
• Guillain-Barre Syndrome
• Aspiration pneumonia
• Organophosphate Poisoning
• Porphyria

10. PAF Hospital , Islamabad
Events
• Type 2 respiratory failure with anoxic brain damage causing low GCS
• He was weaned off of mechanical ventilation
• Extubated the next day (19.07.2023)
• Improvement clinically within 24 hours
• After 2 days: empirical pyridostigmine
• Fully conscious and alert, communicating verbally, pupils were reactive, he was
moving all 4 limbs and cough reflex was present
• bilateral ptosis, could not swallow and power was 4/5 in limbs
• Nasogastric feeding
• RR and ABGs improved
• Speech and Physiotherapy

11. PAF Hospital , Islamabad
Events
• Later patient was able to give history himself and admitted
that initially he developed lower limb weakness
• All weakness reversed in two to three days
• Able to swallow and walk by the 5th DOA
• NG tube and Foley’s catheter removed

12. PAF Hospital , Islamabad
Further Investigations
• NCS: negative for GBS
• RNS: decremental response of > 10% - suggestive of MG
• Ach-R antibody and anti Musk antibodies negative
• CSF Studies: normal

13. PAF Hospital , Islamabad
Outcome
• Successfully extubated
• No residual weakness
• Able to perform daily life activities

14. PAF Hospital , Islamabad
Analysis
Evidence which supports neurotoxic snake bite:
• Hx of sleeping on mattress
• acute onset of neurological symptoms
• rapid deterioration in condition
• Response to symptomatic treatment
• Neurotoxic snake bites (usually Krait) cause mild to no swelling at
the site of bite
• Their fangs are grooved
• cannot bite through clothes and inject complete dose of venom
• painless, no fang marks

15. PAF Hospital , Islamabad
Analysis
The evidence against the MG:
• patient’s age (Usually 20 to 40 years age group)
• Very acute presentation of symptoms
• seronegativity for antibodies (anti-acetylcholine antibodies
have 80 to 90% sensitivity in diagnosis of MG)

16. PAF Hospital , Islamabad
Literature Review
• case series done in India
• Neuroparalytic snake bite masquerading as acute abdominal pain in children
• Four children from a rural background were admitted successively over one
month during rainy season
• presented with acute abdominal pain
• later developed limb weakness, respiratory difficulty and bulbar symptoms
• All were given supportive care
• three cases required mechanical ventilation
• Three cases received ASV
• The patient who received ASV earlier during the course of the illness had quicker
recovery and shorter duration of stay in hospital

17. PAF Hospital , Islamabad
Key Learning Points
• If patient presents with sudden weakness
• Especially in rainy season
• History of sleeping on the ground
• Suspect Snakebite – may be painless, absent fang marks
• Give trial of ASV

18. PAF Hospital , Islamabad
THANK YOU
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